Background Advance decisions to refuse treatment (ADs) are widely discussed as important means to enhance patient autonomy at the end of life even where patients are no longer able to communicate themselves their will. The Council of Europe recommended twice that all member states should adopt legislation on ADs and some countries such as England, Germany, and France recognise legal value to ADs. Yet, in practice these documents are only infrequently implemented.

Aim The paper aims to examine problems physicians from England, Germany, and France associate with regard to ADs, and more generally EOL decisions. The paper will show how the  place accorded to patient preferences influences the potential role of ADs in ethics guidance and policies in the three countries.

Methods 1. Literature review; 2. Four months of ethnographic direct observations in university hospitals in each country in neuro-oncology, neurology (ALS), and oncology; 3. Approx. 45 interviews with physicians in England, Germany, and France.

Results and discussion The analysis reveals differences in the way patient preferences are taken into consideration in the legal context, in the public debate and professional guidelines, and by physicians. The paper shows how this influences physician’s attitudes towards end-of-life decisions in general, and more particularly towards ADs.

Conclusion Understanding the differences between the physician-patient relationship in both countries helps to inform the kind of policy and ethical guidance that should be developed. It follows that a comparative approach of these countries is an important first step in developing comprehensive recommendations for the use of ADs.